These are lesions/injuries on the lining of the stomach or duodenum caused by erosion by pepsin and gastric acids .
This definition excludes carcinoma and lymphoma, which may also cause gastric ulceration, and also excludes other rare causes of gastric and duodenal ulceration such as Crohn's disease, viral infections and amyloidosis.(Roger Walker, clinical pharmacy and therapeutics, 5th edition).
Signs and symptoms of peptic ulcers disease.
Peptic ulcer disease usually presents as dyspepesia. however, not all patients with dyspepsia have peptic ulcer. Dyspepsia is defined as recurrent or persistent pain or discomfort in the upper abdomen. Dyspepsia is caused by gastroesophangeal reflux disease, gastric cancer pancreatic or biliary disease.
Causes of peptic/duodenal/stomach ulcers
Helicobacter pylori(H. pylori)
Helicobacter pylori causes about 90% of duodenal ulcers and about 80–85% of gastric ulcers. It is transmited throgh Fecal oral route The bacteria lives in the acid secreting parts of the stomach. The bacteria survive by producing ammonia that neutralizes the acid around the organism.
How helicobacter pylori causes ulcers.
helicobacter pylori produces cytotoxins(chemicals toxic to cells). These toxins initiate an inflammatory cascade. The bacteria also produces other enzymes that directly erode the gastric lining. These enzymes are urease, haemolysins, neuraminidase and fucosidase. H.pylori also increases the production of gastrin, an enzyme that stimulates release of gastric acid and hydrochloric acid.
Prolonged use of painkillers (NSAIDs/Analgesics)
Non-Steroidal Anti-inflamatory Drugs(NSAIDs) cause stomach ulcers by inhibiting synthesis synthesis of Prostagladins E2 an enzyme that increases blood flow to the gut, reduces gastric acidity, and synthesis of protective mucus lining. This is by inhibiting COX 1 which is the enzyme that stimulates sysnthesis of Prostagladins E2. It is therefore advisable to use cox 2 selective drugs like celecoxib and meloxicam.
How NSAIDs cause ulcers
This rare syndrome consists of a triad of non-β islet cell tumors of the pancreas that contain and release gastrin, gastric acid hypersecretion and severe ulcer disease.
Extrapancreatic gastrinomas are also common and may be found frequently in the duodenal wall.Surgical resection of the gastrinoma may be curative. Medical management consists of greater than standard doses of PPIs. The somatostatin analogue octreotide is also effective but has no clear advantage over PPIs. Patients with idiopathic peptic ulcer disease should be investigated for Zollinger–Ellison syndrome and gastrinoma.(Roger Walker, clinical pharmacy and therapeutics, 5th edition)
Severe physiological stress such as head injury, spinal cord injury, burns, multiple trauma or sepsis may induce superficial mucosal erosions or gastroduodenal ulcerations. These may lead to hemorrhage or perforation. Nasogastric tube administration of sucralfate (4–6 g daily in divided doses) have been used to prevent stress ulceration in the intensive care unit until the patient tolerates enteral feeding or intravenous ranitidine 50 mg every 8 h reducing to 25 mg in severe renal impairment.
Signs and symptoms of stomach/duodenal/peptic ulcers
- upper abdominal pain that occurs one to three hours after food. This is usually relieved by antacids or food. Relieve by food is more marked in duodenal ulcer.
- complications like blood in vomitus, blood in the stool.
- dull pain in the stomach
- weight loss
- not wanting to eat because of pain
- nausea or vomiting
- If the ulcers have been caused by h.pylori, there is smell of ammonia in breath.
Management of peptic/duodenal/gastric ulcer
Before treating the ulcers, one should establish the cause as treatment depends on the cause of the gastric ulcer.
First test for H.pylori.
Management of H.Pylori positive ulcers.
The goal of the treatment is to eradicate h. pyroli. This is done using antibiotics and proton pump inhibitors(reduce production of acid).
One can use either of the following regimen; (H.pyroli kits)
- ESOMEPRAZOLE/CLARITHROMYCIN/AMOXICILLIN /20/500/1000G. Available as a kit. this shoul be taken twice daily for 1-2 weeks. This should then be followed by taking esomeprazole 40m or omeprazole 20mg daily for one week and esomeprazole/omeprazole 20mg at night for another week.
- LANSOPRAZOLE/CLARITHROMYCIN/AMOXICILLIN 30/500/1000. This is also available as a kit. this shoul be taken twice daily for 1-2 weeks.This should then be followed by taking esomeprazole 40m or omeprazole 20mg daily for one week and esomeprazole/omeprazole 20mg at night for another week.
- TINIDAZOLE/PANTOPRAZOLE/CLARITHROMYCIN 500/40/250 MG. This is also available as a kit. this shoul be taken twice daily for 1-2 weeks.This should then be followed by taking esomeprazole 40m or omeprazole 20mg daily for one week and esomeprazole/omeprazole 20mg at night for another week.
If the ulcers have been caused by anything else, the the following can be used.
Sucralfate 1gram three times daily for 6-8 weeks. Examples of brandnames of sucralfate are, sucrafil, crafilm, ulgasul.. sucrafate acts by putting a protective cover on the ulcers and gives them time to heal.
Note ulcers that have not been caused by H.pylori should be carefully investigated.
Algorithm for treatment of gastric/duodenal ulcers
Complications of stomach/duodenal ulcers
Bleeding peptic ulcer. This can lead to anemia and if not treated can lead to death. Tranexamic acid can be used to stop the bleeding. Adrenaline injection can also be used.
Pyloric stenosis. This is narrowing of pylorus which makes it hard for food to pass to the small intestines. Conventional treatment can help. If medical therapy fails to relieve the obstruction, endoscopic balloon dilation or surgery may be required.
Perforation. This is an emergency and requires surgical intervention.